1/14
BIOMATERIALS
[Adopsi dari: Michael M Domach,
Introduction to Biomedical Engineering,
Pearson Prentice Hall, 2004,
CHAPTER 12.]12.1 PURPOSE OF THIS CHAPTER
The previous chapter discussed how bioengineers develop complex and useful devices such as artificial hearts by using their knowledge of fluid mechanics and an understanding of blood’s cellular composition and rheology. Insuring that damage to cells does not create a new problem, while trying to remedy a current medical condition, is a major accomplishment. The choice of materials to use for constructing artificial organs and implants is also an important consideration. Material reliability is essential, because a malfunction can be life-threatening. Moreover, even when a malfunction is not immediately life-threatening, the repair or replacement of an implanted device often requires major surgery, which has risks associated with it. The materials used also must not be toxic or engage the body’s immune and wound-healing systems. When such systems are activated, the device’s performance may be compromised, or new problems created, such as blood clots and strokes.
Research on biomaterials and technology development covers a lot of ground. Practitioners possess knowledge of material science and engineering, which provides the basis for inventing or selecting materials that will provide adequate strength, durability, and other desirable properties. This knowledge also enables biomaterial engineers to characterize the function-related properties of natural materials in order to learn more about how nature has engineered them to work so well. Apart from advancing our basic understanding, these measurements provide performance targets for engineered replacements. Most biomaterial engineers also understand what responses from the body should be avoided when materials are implanted, and how those responses are triggered. This knowledge also guides their decisions on material design and selection. There are experts on using metal alloys, polymers, and other classes of materials. The Society for Biomaterials (http)/www.biomaterials.org/pub.htm) is a major international organization that fosters research and the communication of results in journals and at regular meetings.
Parts of the field of biomaterials engineering have recently merged with that of tissue and cell engineering. Interesting work is now being pursued on combining cells and engineered appliances and devices for the purpose of building hybrid artificial organs. Biomaterial knowledge is also integral to constructing the scaffolds used in tissue engineering. Chapter 8 provided one example, the use of degradable polyesters. An implanted system must not engage the body’s defense systems, while at the same time the goal of a functional, replacement tissue must be achieved.
This chapter will first describe three useful concepts in materials engineering to introduce how properties and design goals can be quantitatively assessed and communicated. Then, the body’s wound repair system will be surveyed, since it presents a hurdle that a biomaterial engineer must surmount. An overview of the immune system will then be presented. Examples of how the three properties drive use and performance as well as provide the impetus for material modification will conclude this chapter.
12.2 THREE BASIC QUANTIFIABLE FEATURES OF BIOMATERIALS
2/14
Elastic modulus. When a material has a tensile force applied to each end, as shown in Figure 12.1, it tends to stretch. The increment in stretching relative to the unstressed length is known as the strain (ε), which on a percentage basis is defined as
100
× −
= ε =
length Original
length Original length
Stretch
Strain (12.1)
Initially, the strain will be proportional to the stress (σ = Force/cross-sectional area) applied as shown in Figure 12.1. The initial ratio of the stress to the strain is called the elastic modulus (E====σ/ε); this ratio is also referred to as the Young’s modulus. When units of newtons and meters are used for stress (Force/Area = newtons/rn2), the modulus has units of pascals, because strain is dimensionless. However, because strain can be a small number for a stiff material, modulus values are often reported in giga Pascals (1 GPa = 109 Pascals). The greater the value of
E, the more resistant to deformation the material is, and thus such a material is “stiff”. The acquisition of stress-strain data is called tensile testing. Standardized protocols have been developed by the American Society for Testing and Materials (ASTM) in order to facilitate the reproducibility and comparison of data from different laboratories. Values for a variety of materials can be found in Table 12.1.
FIGURE 12.1 Tensile testing of a material. (Left) When a force is applied, the material’s initial length (Lin) is increased to Lin +∆L. (Right) The resulting
stress-strain curve and some of its important characteristics.
Table 12.1
Examples of Materials and Modulus of Elasticity
Material Modulus of Elasticity 106 N/m2
Diamond 1 2000 000
Steel 210 000
Copper 124 000
Aluminum 73 000
Glass 70 000
Bone 21 000
Concrete 17 000
Wood 14 000
Plastics 1 400
3/14
If a material returns to its original length (shape) after the stress is removed, it is known as elastic under the stress-loading conditions applied. However, after experiencing higher stresses, some permanent deformation may occur as evident by the material relaxing to a length that is distorted from the original. The permanent deformation is known as an offset and the condition is shown on the stress-strain curve in Figure 12.1. As the stress is continually increased, eventually the material will fail by breaking into two parts. Prior to failure, the apparent elastic modulus will decrease and the material is easily deformed; then it is called ductile. The stress required to break the material specimen is called the tensile strength. Because this stress is not divided by a strain value, the numerical value of the elasticity can exceed the magnitude of the tensile strength. The area under the stress-strain curve has the units of work and energy; this area is called the toughness and is indicative of how much a material can “take” before failure occurs.
Surface roughness. Vessels and organs are composed of cells and molecules; hence, biological surfaces have a characteristic texture and a low, molecular-scale value of roughness. The simplest way to quantify surface roughness is to obtain a height-profile along some track on the surface by using a sensitive gauge. Typically, an average peak height exists with smaller and larger peaks appearing with some frequency. The irregularity of a surface can be quantified by computing how a series (n) of height measurements at different spatial positions along the track (s(x)) compares with the average (s(x)) height. The value calculated by the following equation (σs) is called the root mean square (rms) roughness, and the equation should be reminiscent of
how the standard deviation on an exam is calculated:
[
]
describe surface roughness and topography. Some parameters attempt to capture whether features exist such as periodicity in the roughness pattern. Different parameters are inspired by statistics and also the mathematics used for image analysis. Image analysis involves using computerized, mathematical calculations to process the bits of data that compose an image for the purpose of revealing patterns and/or unique features. The codification of discriminating features in a scan of one’s fingerprint by a crime lab is one example of image analysis. The analysis of surfaces through surface profiling and image analysis tools is also important after a biomaterial has been used. Analyses of explanted devices (surgically retrieved from a patient after implantation), such as artificial hip joint scan shed light on the wear mechanism and other fates that limited their useful life or led to failure.Surface wetting and contact angle. The testing of a material or surface treatment with real biological molecules and cells, as will be described later, provides a gauge of how an implant will perform in the human body. However, it is also desirable to relate such performance to another fundamental property of the biomaterial surface. Establishing a relationship will contribute to the theory of biomaterial design. Another pragmatic outcome is that it becomes possible to detect possible alterations in material surface properties prior to implantation when variations in material fabrication, implant manufacture, implant storage, and/or sterilization protocols occur.
4/14
(i.e., hydrophilic) surface would instead tend to foster the adhesion of water molecules with the result that a droplet would smear out to maximize the area of water-surface contact.
FIGURE 12.2 The contact angle is geometrically defined as the tangent of the interface formed where liquid, solid, and gas phases intersect. From left to right, examples of 45, 90, and 135-degree contact angles are shown. The force balance on the far right dictates that the contact angle formed is the resultant of three interfacial tensions: liquid-vapor (γlv), solid-liquid (γsl), and solid-vapor (γsv).
High or low “beading” depends on the observer and is a fuzzy description. A more precise and quantitative description is provided by a contact angle measurement. The geometric definition of a contact angle, and a sense of what the angle’s magnitude means, are shown in Figure 12.2. The contact angle is the angle assumed by a liquid where three phases (liquid, solid, and gas) intersect. An angle less than ninety degrees corresponds to liquid spreading as opposed to beading. In this case, the liquid is referred to as wetting the solid. A zero contact angle indicates the extreme of complete wetting. When the angle exceeds ninety degrees, we obtain the familiar beading that occurs on water-repelling surfaces. The surface in this case is called nonwetting, and the higher the angle, the more extensive the beading that occurs.
The contact angle attained depends on the resolution of three forces. To acquire a sense of what is involved, omit the presence of a solid and consider water in contact with air. The cohesive forces between water molecules are high and greater than the attraction between water and air molecules. Thus, the water molecules tend to maximize their association with each other while minimizing the number of air molecules that they contact. The result is that the area of the surface that divides the water and air phases is minimized. This is why water droplets and mists attain a spherical shape in air as opposed to an ellipsoid or other shape. For a fixed volume, a sphere is the geometric shape that has the minimum surface-to-volume ratio.
The tendency of water molecules to stick together manifests as a surface tension. A tension is a force per distance. Here, the surface tension force acts along the phase boundary and the distance scale is the along the water drop perimeter. The result is that water and other liquids behave as if they have an elastic skin. Because force per distance is dimensionally equivalent to work (or energy) per area, some people find discussing interfaces easier in terms of interfacial energies (energy per area). In other words, when three phases are in contact, there is an energy scale and total energy associated with the areas that divide the gas-liquid, gas-solid, and liquid-solid phases.
The two equivalent views permit one to use mechanical or thermodynamic viewpoints to describe interfacial phenomena, which are the events and interactions that occur when materials of different phases encounter each other. To illustrate, consider an insect landing on a water surface. The insect’s legs dimple the surface and rather than sinking, the insect’s mass is supported akin to a person standing on a trampoline. The insect is supported because the water surface has a mechanical tension. However, work must be performed to distort the interface. Taking instead the energetic viewpoint, the air-water interface has an energy and area associated with it. The dimple creates more area and thus alters the energy from the prior equilibrium state.
The contact angle attained depends on how the various surface tensions balance out. For a liquid in contact with a solid and air, the liquid-vapor, solid-vapor, and solid-liquid surface tensions are denoted as γlv, γsv , and γsl respectively. Based on the force diagram in Figure 12.2, the contact
angle is provided by the Young Equation:
sl sv
lv = θ=γ −γ
5/14
From inspection, you can find that as the solid-liquid surface tension increases relative to the solid-vapor surface tension, cosθ become negative, which indicates that the contact angle exceeds ninety degrees. This force then helps drive the attainment of the nonwetting condition.
The contact angles formed at water-biomaterial interfaces are commonly measured before and after a treatment that is intended to enhance function or biocompatibility. A treatment may seek reduced wetting to minimize interactions with biological molecules or cells. However, the binding of proteins and cells to surfaces can involve multiple interactions and structural changes involving both the material surface and the adsorbing entity. Thus, some treatments may attempt to fix electrical charges on the surface in order to ‘repel” negatively charged cells or molecules. In this case, the surface may become more wetting. In both cases, however, contact angle measurements can indicate whether the surface was in deed modified. Such an assurance is useful because subsequent tests can be time-consuming and expensive, so it is important to determine whether it is worthwhile to proceed.
Contact angle measurements are quite good for detecting whether regions of a surface differ or if variability in manufacturing or storage conditions results in batches with different surface properties. Additionally, environmental influences on materials can be detected. For example, some workers report that the contact angle formed at a polymer-air-water interface can change if the person performing the measurement is wearing strong perfume or cologne. The fragrance molecules can adsorb to the polymer surface and thus alter the surface and its interfacial energetics. Overall, the basic contact angle measurement or variations are well established in biomaterials engineering. Contact angle measurements provide a convenient way to describe and communicate the nature of a biomaterial surface and whether a given treatment affects wettability. Other applications include quality control, and assessing the effects of aging and the impacts made by storage or implant environment.
12.3 BODY RESPONSE TO WOUNDING
Having considered three properties, we now review the biological phenomena that material surfaces will be exposed to, or can help initiate. Thereafter, examples of how the bulk and surface properties of materials play a role in performance will be provided.
Blood coagulation. The five liters of blood in a human are capable of considerably more than circulating oxygen-carrying, red blood cells. Blood can be viewed as a highly engineered tissue that carries a tool kit for fixing problems and the ainte11igence* to know when to react and when to desist. When blood vessels are damaged or severed, blood reacts to form a patch that isolates the leak and stems blood loss. The process of forming a patch is referred to as coagulation or clotting. The patch is called either a clot or thrombus. The clot is composed mostly of a protein, fibrin. The fibrin network can entrap red blood cells as shown in Figure 12.3, resulting in further restriction of blood flow and leakage from a wounded area.
Clot formation stops after the immediate area of damage is dealt with, which is fortunate because if the process were not well-controlled, entire vessels would contain clots, or the process would happen haphazardly. The unnecessary blocking of blood supply can lead to ischaemia (oxygen deprivation) and tissue damage. These reactive features of blood help to preserve blood inventory when vessels are cut or ruptured. The regulation and preservation of blood volume is called hemostasis, a term akin to homeostasis.
6/14
In larger vessels, the third and major event is clot formation. Clotting can occur by two pathways: intrinsic and extrinsic. The intrinsic pathway uses molecules that are solely present in the blood. The extrinsic pathway uses blood-born factors, plus the activity of some cells that compose the blood vessels. That is, the blood constituents and vessel cells “communicate to coordinate clot-building activities.
FIGURE 12.3 (Top) Activated platelets and (bottom) a blood clot containing a fibrin net work and trapped red blood cells.
Many molecular factors are involved in either the intrinsic and extrinsic path ways. The key feature of the pathways is that cascade amplification occurs. Cascade amplification occurs when one amplified output serves as an input into another amplifier. Several music amplifiers coupled by microphones can illustrate how a cascade amplification system works. Envision that the output from an amplifier connected to a strummed guitar is picked up by a microphone placed in front of the speaker. If the microphone is connected to a second amplifier, the first amplifier’s output will be enlarged by the second amplifier. Several serial microphone pickups and amplifications can significantly enlarge the first amplifier’s output.
7/14
10,000 molecules of fibrinogen to fibrin. The process is further accelerated by the stimulatory effect of thrombin. The amplification provided by each enzyme output being used as a catalyst for the next reaction, in tandem with the stimulatory effect of thrombin, results in a rapid clotting response.
General biomaterial engineering implications of blood coagulation. Coagulation can also occur when blood encounters a foreign surface. The clots that form may interfere with the function of the implant. More importantly, the clot material may also detach, resulting in a blockage elsewhere in the circulatory system. A blockage may manifest as a stroke. A clot fragment is called an embolus and when detachment and blockage of a vessel occurs, an embolism is experienced. A stroke is a common manifestation of an embolism and it involves the restriction of blood flow to the brain.
FIGURE 12.4 Simplified schematic of the clotting cascade. The end-product, thrombin, is produced by a sequence of reactions that each produce an active enzyme from an inactive precursor. Each enzyme assists in catalyzing the next step. The compounding of turnover
numbers results in signal amplification and rapid clotting response.
Embolisms and strokes are major concerns. Indeed, two of the first five recipients of the AbioCor total replacement heart experienced strokes weeks to months after implantation in 2002. Researchers localized the problem to a plastic cage that is involved with fitting the device to an artery. Newer versions of the replacement heart are not fitted with this cage. Apparently, the cage provided a surface and/or source of irritation that triggered the coagulation response of blood. Arterial flows close to the heart can be Large and provide substantial shear forces for the detachment of clot material.
Anticoagulation drugs such as heparin and coumadin can be administered to interfere with the clotting process. Many anticlotting drugs either slow the clotting cascade or stimulate the molecular processes that the body uses to destroy clots by binding to the molecules involved. Other drugs such as streptokinase and tissue plasminogen activator directly attack and destroy new dots. New clot-dissolving products such as TPA are the result of genetic engineering research and development along the lines covered in Chapter 8.
12.4 IMMUNE SYSTEM DEFENSE
The body’s immune system provides another layer of defense. This system attacks and neutralizes foreign cells and substances. If an implanted biomaterial engages the immune system, the results can be damage to surrounding tissue and/or compromised implant performance.
8/14
defense. Additionally, a series of molecular- and cell-mediated amplification steps occur that result in the rapid onset of a defense in reaction to an insult. Interestingly, there are short-term and long-term responses mounted by the immune system that challenge the biomaterials engineer.
Triggering and Response. The immune response is triggered when substances that are not native to one’s body are recognized. Such substances are called antigens. Antigens are typically particular carbohydrate or protein molecules that are associated with foreign entities such as cancer cells, transplanted organs, bacteria, and viruses. Foreign particles and other molecules can also be antigenic. A “piece” of the antigen, as opposed to the whole antigen, is actually responsible for an immune response. Each “piece” of an antigen that is associated with an immune response is called an antigenic determinant or alternately, an epitope.
To illustrate how recognition and triggering can occur, a cell called a macrophage can ingest and degrade particles. The ingestion process is called phagocytosis. When a foreign microbe possessing an antigen is ingested by a macrophage, the microbe is likewise degraded. However, degradation is not complete. Rather, some recognizable remnants of the microbe’s antigen, in combination with a class of major histocompatibility complex proteins, are sent to the macrophage’s surface. The surface-bound combination can, in turn, bind to some proteins on the surface of another type of cell in the immune system. The specific binding event plays a role in all the signaling events that activate and direct the immune system response. The immune defense entails producing antibodies and killing infected native cells and “invaders.” Antibodies are large proteins that can bind a particular antigen. Most antibody molecules have two antigen binding sites. Antibodies help with vanquishing an invader in a number of ways. For example, antibodies with multiple binding sites can aggregate individual microbes into large particles. Therefore, each time one phagocyte ingests and degrades one particle, many microbes are removed from the body. Concerning cell killing, native cells that are infected with a virus can present an alien “signature.” This presentation allows killer cells in the immune system to recognize them and remove them from the body in an effort to contain an infection. This mechanism is also important in checking for the presence of cancer cells and removing them.
Some small molecules not necessarily associated with viruses and bacteria can also induce an immune response only after they combine with other molecules. A hapten is such a small entity. Substances in the background can also heighten the immune response, although it cannot be determined exactly how they participate in the response to a specific antigen. Such substances are termed adjuvants.
Overall responses to biomaterial Implantation. When biomaterials are implanted into the body, there is either a normal injury response or another, much less desirable response. The responses are mounted against the surgery involved and against the material itself. Acute inflammation normally occurs when the biomaterial is nontoxic or otherwise reasonably compatible with the body. Immune system cells first ingest and destroy the damaged tissue and debris associated with the implant. Blood clotting mechanisms such as platelet activation also operate. Thereafter, fibroblasts migrate to the area and synthesize a natural matrix composed of the protein collagen. This matrix fosters the filling in of the wounded area with new cells and tissue. After these responses are complete, the implant will have a fibrous capsule around it.
9/14
12.5 EXAMPLES OF THE ROLE OF MECHANICAL PROPERTIES OF BIOMATERIALS
Elastic modulus. The elastic modulus of skin and bone are roughly 1 and 20 GPa, respectively. Corrosion-resistant metal alloys have much higher modulus values; a typical value for stainless steel is 200 GPa. How the modulus of an implanted material compares to a natural material can be quite important. Sometimes, a much higher modulus for the implanted versus a natural material is desirable. For example, when a metal fixture is used to secure a broken bone, one would like the union to be strongly held together to foster healing. If the fixture was “stretchy,” then the breakage area could deflect when a load was applied, which does not foster fast and even healing.
On the other hand, when a degenerated hip joint is replaced by an artificial hip, a metal stem is inserted into the leg bone. The metal stem inside bone can take on some of the mechanical load normally supported by the leg bone. When bone tissues are not mechanically loaded, as can occur during long space flights under reduced gravity conditions, loss of bone mass can occur. Thus, if the implant takes on too much of the stress the bone normally contends with, over the long term bone mass may decrease, which could weaken the union between bone and the implant. Overall, a mismatch between the modulus of implanted biomaterials and natural materials can be desirable, or introduce side-effects that could lead to trade-offs between desirable and undesirable consequences. These trade-offs can be difficult to predict in advance which accounts, in part, for the evolutionary nature of implanted biomaterials.
Surface roughness. One obvious consequence of surface roughness occurs when the implant has a moving part. If surface roughness is high, then ‘high spots” called asperities can make contact with the opposing surface. If the two surfaces are hard and rough, then the asperity contacts can result in significant friction. If the rough surface is harder than the opposing surface, then the soft surface will experience wear and become marred by scratches or plough tracks. Apart from the friction, surface wear, and reduced lifetime, another important consequence is that wear particles can be shed. The consequence of such particles on the biological response to an implanted material can be high, as will be discussed later in this chapter.
12.6 EXAMPLES OF BIOMATERIALS ENGINEERING STRATEGIES THAT ATTEMPT TO MINIMIZE CLOTTING THROUGH SURFACE
MODIFICATION
The arsenal of established and new drugs reduces the risk of blood clots and provides ways to treat clots when they occur. However, because all drugs have side effects, biomaterial engineers continually strive to conceive of ways to limit the onset and extent of the clotting process through the design of the material’s surface chemistry and morphology. Numerous strategies have been developed. One obvious strategy is to engineer a surface such that cellular and molecular interactions are minimized. Here, the idea is to make the surface as passive as possible, such that platelet adhesion and other clot formation events do not occur. A second and opposite strategy is to encourage cell adhesion and in-growth. In this case, the aim is to encourage alteration of a material’s surface after implantation to the point that the cells and molecules presented are those that naturally appear in the body. Lastly, chemical signals can be integrated with the material for the purpose of “jamming” the signals that initiate and propel clot formation. Examples of these different strategies follow.
Limiting roughness. One obvious strategy is to process biomaterials to achieve a smooth surface. The rougher a surface is, the more surface area exists for molecular and cellular adhesion. Such interactions with blood constituents can initiate coagulation. Therefore, the AbioCor artificial heart designers used smooth plastics to construct the pumping chamber materials and surfaces. The smooth surface in combination with the fluid flow pattern and resultant shear forces are intended to limit the deposition of biological material on the blood-exposed surfaces.
10/14
of polyethylene oxide (PEO) polymers to blood-contacting surfaces is one frequently used chemical treatment. Polymers were introduced in Chapter 8 by using polyglycolic acid as an example of a tissue engineering scaffold (see Figure 8.3). Recall that a polymer is a large, chainlike molecule where repetition of a constituent structure occurs. A physical model of a polymer would be a chain of beads, where each bead is the same color. A copolymer is formed from two different monomers; it is comprised of different segments or “blocks” that often differ in chemical properties. Thus, envision a copolymer to be a chain of beads where the beads have different colors, and it is also possible for branches to exist.
Attaching polymers to a surface can discourage protein and platelet adsorption for a number of reasons. One mechanism is called steric blocking. Here, the polymer molecule’s surface coverage and extension from the surface blocks a protein’s or platelet’s access to the surface, much like how, in U.S. football, an offensive lineman tries to protect a quarterback. Of course, the interaction between PEO and the molecules and cells that are being denied access to the surface must be neutral or repulsive, or the PEO would simply serve as a way to link the surface to proteins and cells.
One demonstration of this technology is shown in Figure 12.5. Copolymers were synthesized of methyl methacrylate (MMA), polyethylene oxide (PEO), and vinyl sulfonic acid (VSA) in order to passivate a polyurethane (PU) surface to protein and platelet adsorption. The MMA block was intended to adsorb to the PU. The PEO and VSA blocks were intended to discourage protein and platelet adsorption. VSA was chosen for the negative charge it can provide to its segment of the polymer. Because platelets and many proteins possess net negative charges, VSA may provide forces that repel platelets and proteins.
Contact angles for the raw and treated PU materials were measured. Untreated PU exhibited a water contact angle equal to 57 degrees. The treated materials presented reduced contact angles ranging from 40 to 45 degrees. The surfaces were thus more wetted by water, which is consistent with the hydrophilic nature of the attached polymer chains. In this case, a contact angle measurement confirmed that a chemical modification indeed occurred. Additionally, how the material properties changed made sense based on the knowledge of how the polymers interact with water.
The results were encouraging, as indicated by the diminished extent of platelet adsorption on surfaces bearing the highest PEO content (Figure 12.5; C and E). The surface treated with the highest PEO- and VSA-containing copolymer was particularly effective, as measured by the low platelet adsorption over two hours. Protein adsorption results were interesting as well. Some surfaces displayed low albumin adsorption, while other proteins, such as fibrinogen, were found to avidly bind. Other surfaces displayed low adsorption of all blood proteins rested. Low protein adsorption or preferential adsorption of albumin over fibrinogen is very important. Albumin coating tends to “hide” the surface from the blood coagulation process, whereas surfaces with adsorbed fibrinogen are linked to platelet adsorption.
In general, it is challenging to predict exactly how the adsorption of a particular protein will be influenced by the chemistry of a surface. While proteins possess a net charge, there are patches of different charges on a protein’s surface that still may permit an electrostatic interaction to occur between a protein and a surface. Moreover, proteins can unfold or change conformation when they adsorb onto a surface. Changes in a protein’s three-dimensional structure can introduce new ways for a protein to interact with a surface.
11/14
Surface treatment to inhibit clotting cascade. Another approach is to treat a biomaterial surface so that even if the cascade mechanism is activated, blood clotting proceeds to a limited extent. Heparin, as noted earlier, can be administered to minimize dotting. Heparin is a sulfonated, polysaccharide chain with a molecular weight that ranges from 3,000 to 30,000. In essence, heparin is a naturally occurring chain of sugar molecules that possess sulfate groups. Heparin is an inhibitor of thrombin. The extent of inhibition increases after it interacts with another molecule present in the blood.
Ways have been devised to use the anticoagulating properties of heparin at the site it is most needed rather than dispersing the molecule throughout the blood stream via an infection. By attaching heparin to a biomaterial surface, the blood in contact with the surface is inhibited from clotting, whereas blood elsewhere in the body “sees” less heparin. The advantage over intravenous administration is that clotting can occur elsewhere in the body in case an injury occurs, while clotting is minimized in the vicinity of the implanted material.
12/14
FIGURE 12.5 Outline of a surface engineering strategy and the effects on platelet adhesion. (Top) The raw material is polyurethane (PU). Different surface possibilities are envisioned by coating polymers onto the PU surface: (a) none, (b) hydrophobic polymethyl methacrylate (PMMA) back bone adhered to the surface with negative charges protruding from attached moiety, (c) PMMA backbone and polyethylene oxide chains (PEO) protruding, (d) PMMA backbone anchoring polymer to surface with negative charges and PEO chains protruding, and (e) PMMA backbone anchoring polymer to surface with more negative charges and PEO chains protruding. The corresponding outcomes in terms of platelet adhesion after two hours of exposure of platelets to treated surfaces. Preparations C and E exhibit the least platelet adhesion.
Reproduced with permission from: MMA/MPEOMA/VSA copolymer as a novel blood-compatible material: Effect of PEO and negatively charged side chains on protein adsorption and platelet adhesion. Jin
Ho Lee, Se Heang Oh, Journal of Biomedical Materials Research, 60, 1, (2002): 44-52
(http://www3.intercience.wiley.com/cgbin/fulltext/89013899/main.html,ftx_abs).
Surface design that works with nature. Another approach is to engineer a material to do the opposite of what die prior two examples strive to achieve. Instead of engineering passivation or clotting inhibition properties into a biomaterial’s surface, the different approach is to foster maximal interaction between the biomaterial and biological materials.
The HeartMate LVAD provides an example. The material of the blood-pumping chamber is deliberately designed to be rough and encourage cell and protein adsorption. The intent of using high surface area materials is to rapidly and extensively coat the blood-contacting surfaces with a variety of cells and molecules found in the patient’s body. The coating is thought to allow the biomaterial surface to “blend in” and thus not trigger wound repair and blood coagulation responses. Sintered titanium spheres and rough-textured polyurethane are used to provide high surface areas for blood-contacting surfaces. The incidence of thromboembolisms has been encouragingly low when engineered, rough surfaces are used in the HeartMate LVAD.
12.7 EXAMPLES OF IMMUNE SYSTEM LINKS TO BIOMATERIALS
13/14
immune system. Those with nose and other piercings can experience this allergic reaction, as well as people who wear nickel-containing jewelry.
Specific antibody responses. The repair or replacement of large arteries such as the aorta is challenging because it is difficult to harvest comparably strong and large vascular material from elsewhere in the patient. Thus, synthetic materials such as Dacron are used as grafts for replacing sections of blood vessels. Woven and knitted fabrics are available.
Essentially, a “tube” of Dacron fabric is surgically implanted. The blood-contacting surface was initially hoped to be colonized by the endothelial cells that line blood vessels. Such colonization would endow the graft with a surface with low reactivity to blood. Colonization was reported in early studies in animal models. However, colonization is not as extensive in humans, it is confined to the ends of the graft that are sutured ro a blood vessel. A layer of fibrin is instead established over the bulk of the blood-contacting surface. Consequently; the level of thrombosis is not as low as initially hoped and while manageable, thrombosis can be a post-operative complication.
Graft design presents an interesting optimization problem that illustrates the challenging and interesting nature of biomaterials design and engineering. Fabric porosity is one variable. If a fabric is too porous, the blood loss through the graft’s pores immediately after implantation could be life-threatening. On the other hand, if the porosity is too low, then capillary in-growth and cell migration could be impeded. Woven fabrics have lower porosity than knitted fabrics. Thus, knitted fabrics are contacted with the patient’s blood prior to implantation and administering heparin. The preoperative coagulation reactions reduce the porosity. An alternative to pretreating graft material with blood is to use knitted grafts that have been infused with collagen.
Graft compliance is another variable. Compliance can be defined as the change in vessel diameter that occurs per unit of pressure imposed. As described in the prior chapter, normal vessels are elastic and expand when ventricle contraction occurs. If a graft is not likewise compliant, then blood flow through the graft may be restricted. Additionally, the vessel the graft is attached to will undergo dilation when the circulatory system pressure rises, if the graft’s diameter tends not to change in synchrony with the feeder and drainage vessel segments, stresses may be imposed on the sutures that connect the graft to the vessel. The other extreme of excess compliance for a graft is not desirable either. If too compliant, the graft will swell and possibly in vade or irritate surrounding tissue. Excessive compliance may also result in permanent shape distortion.
The antigenicity of the polymers used for grafts is yet another variable. Some studies with animals have suggested that polymer-specific antibodies may be generated (Schlosser et al., 2002). These antibodies, if also produced by humans, could provide a clinical index for the short and long term response of the patient to the graft. Immune responses to implanted materials have to be kept in perspective. The clinical situation prior to implanting an arterial graft is typically serious. If an immune response is kept in check, then the trade-off is positive in that both life span and quality have been elevated. However, documented and proposed immune responses motivate biomaterial engineers to modify or replace materials with synthetic or tissue engineering alternatives.
Adjuvants. The recent controversy over silicone implants illustrates how a material with many desirable properties might present unanticipated problems after a long time frame of usage. An ongoing debate is underway on whether implanted silicone can function as an adjuvant. Such disputes and the ability to find supporting and refuting data in these cases explain why the biomaterials engineering field tends to cluster around similar materials, and the introduction of alternatives is done cautiously.
14/14
Brandon, M.R., Sano, A., 2002.) The latter are molecules that the immune system produces in the process of stimulation. The antigen and adjuvants slowly leach out from the material, thereby keeping the immune system continually on “alert” and poised to deal with a bacterial infection that can plague livestock such as sheep.
Wear particles. Other long-term effects can be presented by implanted materials. Implanted hip joints have improved the quality of life for thousands and the surgery has become almost routine (see Figure 12.6). However, the bearing surfaces, which are typically composed of the polymer polyethylene, can wear with use and shed small particles. Other particles and debris can also be generated from the materials used. These small particles are believed to activate macrophages. The immune response results in erosion of the surrounding bone that secures the implant. Bone loss (osteolysis) can, in turn, result in the implant loosening. Consequently, the combination of wear and loosening limits the lifetime of hip implants.
